The evaluation, diagnosis and care of the surgical patient are primarily the responsibility of the surgeon. The surgeon bears responsibility for ensuring the patient undergoes a pre-operative assessment appropriate to the procedure. The assessment shall include a review of the patient's chart and an independent diagnosis by the operating surgeon of the condition requiring surgery. The operating surgeon shall have a discussion with every patient regarding the diagnosis and nature of the surgery, advising the patient that there are risks involved. It is also the responsibility of the operating surgeon to re-evaluate the patient immediately prior to the procedure.
The attending surgeon retains primary responsibility for evaluation and management of the surgical patient pre, during, and post procedure. Pre-operative assessment should include a complete history and physical examination, as well as a clearly documented Procedure, Alternatives, Risks, and Questions (PARQ) conference. Post operative care will be provided by the surgeon or designee with similar credentialing, certification, and scope of practice. It is the responsibility of the operating surgeon to assure safe and readily available post-operative care for each patient on whom he/she performs surgery.
It is not improper to involve other licensed health care professionals in post-operative care, so long as the operating surgeon maintains responsibility for such care. When non-physician, licensed health care professionals are involved in the care of the patient, the surgeon needs to ensure it is based on what is best for the patient and that the other provider practices within the lawful scope of his/her practice. If co-management is done on a routine basis for primarily financial reasons, it is unprofessional conduct and may be illegal.
Post-operative notes must reflect the findings encountered during the surgery. When identical procedures are done on a number of patients, individual notes should be done for each patient that reflects the specific findings and procedures of that operation.
-Adopted July 2010